HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (2) 727 Main St, Ost — WiannoKnolls
Review of All Septic Systems Jari 2017
PESCE ENGINEERING & ASSOCIATES, INC.
451 Raymond Road
Plymouth, MA 02360
Phone 508-743-9206
' epesce .comcast.net
January 9, 2017
Mr. Thomas McKean. R.S., C.H.'G.
Town of Barnstable
Board of Health
200 Main Street
Hyannis, MA 02601
Subject: Submission of Proposed Septic System Layout Plan, Wianno Knoll
Condominiums, Osterville, MA
Dear Mr. McKean.
As requested at the November 22, 2016 Board of.Health hearing , please find attached
the 4 copies of the "Master" Proposed Septic System Layout Plan for the future septic
system upgrades for the remaining buildings at Wianno Knoll Condominiums, for our
discussion with.the Board of Health at the upcoming hearing on January 24, 2017.
This master layout plan shows the preliminary design layout and sizing for new Title 5
compliant septic systems for Buildings A, B, C, D, G and J units (located in Building F).
These designs as shown do not require variances from Title 5. The sizing of each
septic system leaching area is based on the most recent septic system inspection
reports performed in April 2015 as follows:
Building A (includes units B1 & 133) = 660 gpd
• Building B = 440 gpd
Building C = 880 gpd a .
Building D,= 880 gpd — I o J4 "X�
• Building G = 880 gpd
• J Units (approx. 4,000 sf office) = 440 gpd
I also ask that our previous request for variances to Title 5 for the proposed septic
system repair for Buildings E & F (latest revision dated 10 November 2016),be
approved by the Board. Referencing 310 CMR 15.001 of the State Sanitary Code,
which sets forth the purpose of Title 5 as follows:
"The purpose of Title 5, 310 CMR 15.000, of the State Environmental Code is to provide for the
protection of public health, safety, welfare and the environment by requiring the proper siting,
construction, upgrade, and maintenance of on-site sewage disposal systems and appropriate
means for the transport and disposal of septage. "
t
It is my opinion as a registered professional engineer that the proposed septic system
for Buildings E & F will provide adequate protection of public health, safety, welfare and
Mr. Thomas McKean. R.S.,_C.H.O.
January 9, 2017
Page2
the environment, and satisfies the purposes of Title 5. It is also my professional opinion
that de-nitrifying treatment is not needed for the proposed system and that requiring
such treatment, and the expenses associated with such a requirement, is not necessary
and would be unreasonable.
Thank you for your help with,this project, and as always, please call if you have any
questions.
Sincerely,
Edward L. Pesce, P.E.
Attachment
cc: First Property Management
PESCE ENGINEERING AND ASSOCIATES Phone 508-743-9207
451 Raymond Rd., Plymouth, MA 02360 Fax 508-743-0211
O Legend
Parcels
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F + t9 #27,�. "� ¢ 4 ' Railroad Tracks
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artF"�` f-..,��t � � �.„„'� "'n•"""�. Driveways
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#746 t it tg s a w �g ` Streams
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Water Bodies
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Paths
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13 Improved
Unimproved
t
Swimming Pools
,s 1 i e tit I',s 5 r }F g
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412
3 1 Q In Ground Swimming Pools
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¢ � 3#2 Jr- t \ ,pF � '� - '�.,_��•< i _
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Decks Patios
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a , Stairways
Tanks
qg
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rF ate Tanks _
# 76 Jetties
a.
� d����_ h � r � `� �r� � x � � ` t 'a 7 5Ed = �� — Sports Lines
: <•a t Z: f Recreation Facilities
Sports Areas
a " Golf Areas
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#86`
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Map printed on: 1/24/2017 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit
adequate for legal boundary determination or representations of Assessor's tax parcels.They are
- — Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026oi
0 i67 333 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624
reflect current conditions,and may contain such as building locations.
Approx.Scale: 1 inch= 167 feet cartographic errors or omissions. gis@town.barnstable.ma.us
1/24/2017
Wianno Knoll Condominiums
727 Main St., Osterville, MA
(32 total units)
Septic System Cost Estimate Analysis
Septic System for Buildings E & F with Unit J1 (dentist office)
Cost with Conventional Cost with Denitrrifying
Septic System Septic System
Engineering design and �v\L
Construction Cost $ 90,000.00 $ 145,000.00
Estimate '?S
Cost per unit (32 total) $ 2,812.50 $ 4,531.25
Septic Systems for all 7 Buildings (7 total septic systems)
Cost with Conventional Cost with Denitrrifying
Septic System Septic System
Engineering design and
Construction Cost $ 355,000.00 $ 610,000.00
Estimate
Cost per unit (32 total) $ 11,093.75 $ 19,062.50
The est. cost for denitfiying septic system is: 72% More than a conventional systerr
Pesce Engineering Associates, Inc.
I
1/24/2017
Wianno Knoll Condominiums
727 Main St., Osterville, MA
(32 total units)
' Septic System Cost Estimate Analysis
Septic System for Buildings E & F with Unit J1 (dentist office)
Cost with Conventional Cost with Denitrrifying'
Septic System Septic System
Engineering design and
Construction Cost $ 90,000.00 $ 145,000.00
Estimate
Cost per unit (32 total) $ 2,812.50 $ 4,531.25 {
Septic Systems for all 7 Buildings (7 total septic systems)
Cost with Conventional Cost with Denitrrifying
Septic System Septic System
Engineering design and ,
Construction Cost $ 355,000.00 $ 610,000.00
Estimate
Cost per unit (32 total) $ 11,093.75 $ 19,062.50
The est. cost for denitfiying septic system is: 72% More than a conventional system
Pesce Engineering Associates, Inc.
Y
4V
Commonweonh of Mossochusetls
Executive Office of Environmental Affoiis
Department of
Envr$ronmentai Protection
W1111am F.Weld
Go.nmor
Trudy Coxe
S.cwury,EOEA
David B. Struhs
Commiu:on�,
``// SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
MAP# �7� PART A w/A/!/0910 jrlvklkl- D/ 0J_
PAR# 0/5 066- 11X CERTIFICATION C
,q T
Property Address: 71 7 o-�Ac v�S)-£ Address of Owner.
Date of Inspection: �—/6-f q (If different)
Name of Inspector: 79�fS 72) 5£l,ps
Company Name, Address and Telephone Number:
A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ P es
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
/-0
lnspeotot'a 9lYnature: -�/��Zs�d� Date: 20- 9�.
The System Inspector*hall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design 41ow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D:
Al SYSTEM PASSES: 4
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection
Indicate yea,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
jV0 The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exNtration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
�revired 11/03/95) I
On!VAntft SOO 0 801t0n,Maslaftsette 02106 • FAX(617)5WI049 • Telephone(617)292-SSM
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address;
Owner.
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES(continued)
! Sewage breakout NNIk0ob"rved in the distribution box is due to broken
distribution box. The system will pass inspection if(with approval of the Board of
NAM
Health):
broken pipes)are replaced
obstruction is removed
distribution box is replace
Al
The system required Pumping more than four times a year due to broken or obstructed pipe(s)• The system
inspection if(with approval of the Board of Health): Will pass
broken pipes)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions east which requite further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROT'F.CT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT. - -
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The System has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
suppl,well,unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
` • A.
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address:
Owner.
Date of Inspection:
DI SYSTEM FAIL:
I have determined that the system violates one'or more of the following failure criteria as defined in 310 C 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged S or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters du an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an over ded or clogged SAS or cesspool.
_. Liquid depth in cesspool is less than 6'below invert or available vol is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or p ' is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet f a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a e I of a public well.
Any portion of a cesspool or privy is within 0 feet of a private water supply well.
Any portion of a cesspool or privy is 1 than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If a wgll bas been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic mpounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to lar systems in addition to the criteria above:
The system serves a facility a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the a threat because one or more of the following conditions exist:
_ the system is thin 400 feet of a surface drinking water supply
the system within 200 feet of a tributary to a surface drinking water supply
_ the m is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public
wate supply well)
The owner or opera of any such system shall bring the system and facility into hill compliance with the groundwater treatment program
requirements of 31 CMR 5.00 and 6.00. Please oonsult the local regional office of the Department for further information.
(revised 1/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addreew
Owner.
Date of Inspection:
Check if the following have been done:
V pumping information was requested of the owner,occupant,and Board of Health.
_L/Noae of the System components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection,
/As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
�V e system does not receive non-sanitary or industrial waste flow
e site was ins o petted for signs of breakout.
AA 11
system components,IXcluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
/tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
✓7u site and location of the Soil Absorption System on the site has been determined based on existing information or
ZTapprossynated
by non-intrusive methods. . .
he facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
.(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspeotion:
FLOW CONDITIONS
RESIDENTIAL
Design flow:_-EE O gallons
Number of bedrooms:
Number of current residents:—
Garbage grinder(yes or no): NO /
Laundry connected to system(yes or no): K£S
Seasonal use(yea or no):,j/O
Water meter readings,if available:
Last date of occupancy:
COMM ERCIALANDUSTRIAL-
Type of establishment:
Design flow:_-j;sllons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: Soaker
System pumped as part of inspection. (yes or no)_
If yea,volume pumped: gallons
Reason for pumping:
TYPEQF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any) A
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source of information:
Sewage odors detected when arriving at the site:(yes or no)Ala '
(Mised'11/03/95) 6
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK:_
(locate on site plan) �/¢ f N o.✓ /N f T
' Va
Depth below grade: . /
411
Material of constriction:Vooncrete_metal_FRP—other(explain)
Dimensions O 0 0
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30�'
Scum thickness: /0 ,
Distance from top of scum to top of outlet tee or baffle: G ,,
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) T A,1- f}j Lvo�'i(/Ai F lid /N £T Tf£, /iy,4£T roa s,--
S7 r4- ,gT 61PA4 ouT.LfT np�r�
Sff Gv,4 3 g?F P,.*.o f Z)
GREASE TRAP._
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP _other(explain)
Dimensions:
Scum thicl<�sss:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(e:plain)
Dimensions:
Capacity:_ gallons
Design flow gallonslday
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidenu of leakage into or out of bo:,etc.)
�J 0a JS /�'x�G 3' d���w GiP,¢�£ 57_££L ouf/P 4 T
E S OA )-£gk-/wA� --7''o 46r £ol_ Cf✓7
PUMP CHAMBER:-
(locate on site plan) '
Pumps in wonting order.(yes or no) i
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
L "
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: "
Owner. `
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,but my be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching geilleries,number:
leeching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, s' of h
P/T 'Y/ S 'Q Flow ydrauhc failure, level of pending, condition of vegetation,etcJ
GiPAa F 5o,T1 /
Tw,9 I I
6 FA GR �
41LL Firs .5,�£rL C�ur,�s'
CESSPOOLS:_ T </"3£
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:(Dote condition of soil.signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
I .
(revised 11/03195) 8
f '
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:
Owner.
Date of In"tion:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all well$ within 100'
S F £ -rT,#C 14
DEPTH TO GROUNDWATER
Npth to SrMndwater: / Lfeet �"
method of determination or approximation: / L 5T' / oL F oiv ��®N Nv w��� 7-
(revised 11/03/95) 9
s
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
M -A-,=Cl
DATA
1
•!.a cam, r •t
�,�'' — _ _•_ 1 _ ��---- �JJ �� / _ cam' ..
It
rr" + �
Ile
` � � J y- � ,y 1 •� t•r l�j _ �7P��Jc•r.. _ a:�.�a�:• a�''.. Y � �,.
i
Commonweohh of Mossochusetts
Executive Office of Envifonmentol Affairs
Department of
Environmental Protection
WHtsam F.Weld
Go.nmo�
Trudy Coxe
J.uwury,EOEA
Davld B. SUuhs
�/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA1
MAP# l7 A'1 PART A
11AR# O/3 a 4 4� CERTIFICATION n
Property Add( 7 a.rf /rl/��.v S �,�///�g/,I/O I�/VO�� l oN17oS
P Y r p,s'T/L' V/L Address of Ovner:
Date o! Inspection: /._�`_f1 7 (If different)
Name of Inspector: �M£S '7 S T"5
Company Name, Address and Telephone Number:
A & n Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
We
s
�onditioally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
lwpeotom's Signature: JQ._e_.,ev t.� y Date: 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design-flow of 10,000 gpd or greater,the impector and the system owner shaU submit the
report to the appropriate regional office of the Department of Envimnmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. _
INSPECTION SUMMARY:
Check A,B.C,or D:
Al SYSTEM PASSES:
I have not found wV information which indicates that the aystem violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
__zone or more system components need to be replaced•or�repaired. The system,upon completion of the replacement or repair, passes
inspection..
Indicate'yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfilfration, or tank failure is
y imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved
by the Board of Health.
(revised 11103/95) ` 1
aM"n*Spryt 0 00ston,Massachusetts 02108 • FAX(617)SWI049 9 Telephone(617)292.5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
E. .
Property Address;
Owner.
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES(continued)
rSewage breakout +
in the distribution box as
due to a broken, distribution box. The system Health): will pass inspection it(with approval of the Board of
broken pipe(s)are replaced
obstruction is removed
distribution box is�replace
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced.
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing public health,safety and the environment. to protect the
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUN4,TIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEt�:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTII (AND PUBLIC WA /
R,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PR S T THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is wit hi 00 feet to a surface water supply or tributary to a
surface water supply.
_• The system has a septic tank and soil absorption system and ° within a Zone I of&'public water supply well.
The system has a septic tank and soil absorption system is within 50 feet of a private water supply well.
The system ha a septic tank and soil absorption and is Tess than 100 feet but 50 feet or more fiom a private water
&UPPIly well,unlea a well water analysis for co f bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the p nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
or
(revised, /03/95) ' 2
x
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner. J
Date of Inspection:
D) SYSTEM FAILS:
I have determined that the system violates one'or more of the following failure criteria as defined in 310 MR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what necessary to correct the'
failure.
Backup of sewage into facility or system component due to an overloaded or clogged S or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters d to an overloaded or clogged SAS of
cesspool.
Static liquid level in the distribution box above outlet invert due to an over ded or clogged SAS or cesspool. r
Liquid depth in cesspool i8 less than 6"below invert or available volum is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to ogged or obstructed pipe(s).
Number of times pumped -
Any portion of the Soil Absorption System, cesspool or privy ' below the high groundwater elevation..'
— Any portion of a cesspool or privy is within 100 feet of a ace water supply or tributary to a surface water supply. `
Any portion of a cesspool or privy is within a Zone I a public well.
Any portion of a cesspool or privy is within 60 f of a private water supply well.
Any portion of a cesspool or privy is less t 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the w has been analyzed to be acceptable,attach copy of well water analysis for
eoliform bacteria,volatile organic compou ds,ammonia nitrogen and nitrate nitrogen.
9
El LARGE SYSTEM FAILS:
The following criteria apply to large syste in addition to the criteria above:
The system serves a facility with a d flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environm t because one or more of the following conditions exist:
the system is within 4 feet of a surface drinking water supply'
the system is wit ' 200 feet of a tributary to a surface drinking water supply x`
the system is ted in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone IIf of a public
water supply u)
The owner or operator of any ch system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 6. and 6.00. Please consult the local regional office of the Department for Auther information.;
(rfvtsed 11103/ 3
i
x
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addi,e
Owner. -
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
.None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large vglumes of water have not been introduced into the system recently or as part of this inspection.
XAs built plans have been obtained and examined. Note if they are not available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up.
., The system does not receive non-sanitary or industrial waste flow
J�pe site was inspected for signs of breakout.
_All system components,I9cluding the Soil Absorption System, have been located on the site.
2 septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
V The size and location of h_ t e Soil Abeorptioa System on the site has been determined based on existing information or
approximated by non-intrusive methods.
J71he facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- `
Surface Disposal System. r
(revised 11/03/95) �'
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection
FLOW CONDITIONS
RESIDENTIAL;
Design flow: Ons
Number of bedrooms:
Number of current reeidents:V��N6'&V
Garbage grinder(yes or no):
Iauadry oonaected to system(yea or no): 7 FS
Seasonal use(yes or no): 1✓0
Water meter readings,if available:
Last date of occupancy;
COMMERCIAL/INDUSTRIAL•
Type of establishment:
Design 11ow:_galloae/day
Grease trap present:(yea or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available: `
I.ast date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
7Lr/s1/syz
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: pUons
Reason for pumping:.
TYPE 9F SYSTEM
V Septic taak/distnbution box/soil'absorption system
8ingio carpool
Overflow cesspool
Privy `
j-�Shared=20—
or no) (if yes,attach previous inspection records, if any)
Other .vim •�P �S� Pick S vi° pr% ,�,L�
APPROXIMATE AGE of all components,date installed(if known)and source of information: - I/c 7 �/jll��t/' /►�£l¢/.%Y D
Sewage odors detected when arriving at the site: (yea or no) /VO
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of inspection:
sF.Pnc TANK:YIVoT£ ; ,vk e k
(locate on site plan)
A� 7p KFd P/✓ / - _
Depth below grade: � /
'e,V"
30
Material of eoadn;tion:1Zconcrete_metal_FRP—other(explain)
Dimensions: oaa C#ST
Shidge depth: =_
Distance from top of sludge to bottom of Outlet tee er-b&Q: 3 0
Scum thickness:
Distance from top of scum to top of outlet tee embattle:
Distance from bottom of scum to bottom of outlet tee owe: L
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, dept of liquid evel in relation to outlet invert,structural integrity,
evidence of leakage,etc.) ,c/A—
° INA fT- £f
/V Frofirie Tf£ T /P f cis £T_ afiF al flow
lr/PAD£ ""2112 G/PE Lv Yllyd S
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_FRP_other explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet to or baffle:
Distance from bottom of scum to bottom of outlet to or baffle:
. 4 .
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage.etc.)
S ° '
(revised 11103/95) , .6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:
Owner.
Date of Inspeotion:
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:
Material of construction:_concrete,_metal_FRP—other(explain)>
Dimensions:
Capacity: eallona
Design flow: eallons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: () {
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage-into or out of box,etc.)
D fox iS A# " ZZA-011 671t',93F — ,5'/F tL NufX 4 7— A4) V
f610x /Vf9s✓per i X9�X`. 513CS (vAWF QoA 1v fJS
PUMP CHAMBER:_
(locate on site plan)
Pumps in working orden(yes or no)
ti
Comments: j
(note condition of pump chamber,oondition'of pumps and appurtenances, etc.)
L
(revised 11/03/95) 7
$UBSLIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection: /
SOIL ABSORPTION SYSTEM (SAS): V
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
wing Pits,number:_
leaching chambers, number_
leaching galleries,number: '
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Comments:(note coDtion of soil, signs of hydraulic failure, level of ponding,condition of vegetstion,etc.)
iT /S 6C tr Ff f 'I,vAT iw ^7- . ST£r
Now; /y£ ''a iT vv R it°A�
/� %z S/yGvL B£ C •
CESSPOOLS:
_
(locate on site plan)
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: ---
Indication of groundwater
inflow(ossspool roust be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of coastnxtion
Depth of solids: Dimensions:
Comments:(note ooydition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
------------
(revl`ed 11/03/95) 8
f -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address;-
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
iaclude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
S i9 r7—il c/f 2) o�l AAI
DEPTH TO GROUNDUu TFR
Depth to groundwatert/L feet
method of determination or approximation: O'/y
(revised 11/03/95) 9
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
A- 11 '
�C&' L
M *7� 1�
DATA
+� ! � .! S •,� +� �• � r � �. Ste-! '
� L �� G �•�x�',�} +'' •/'���� Tom' ,�,�`� �..r� (-- .. •�` y r � :�,'t �."`: "
t
- l O _ mot' � r _ _ {� r -� r •-\ u � r- � ( v,
i. � � ��•� �� .. ,. �,_ .__• ----. - __- _ . .. .._ '._ ._ .__. '.ei ' � , � It if }"� - '
1 Ai."l._ ..^i. 'ice ` ...rJ I` ` ~. i:.ff1/ J'• .} _
Ilk
.Yr M.YrYMr••+w r...r. ..+... ,i�IAM^.•Y rw6_.MMY:.si.l"l••� .. � ', 1`.. • .. - ` / 1 �.
Jw
"s � �:a:� � T to�•••'.''.. .� _ -
Commonweanh of Massachusetts
Executive Office of Environmental Affairs
Rartment of
Environmental Protection
W1111am F.Weld
Go"Mor
Trudy Coxe
Ssuusry.EOEA
Davld B. Struhs
cometu,;ono - .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
MAP# f y/ PART A W/d A/.v0 It`N�LL ��ON�oS
PAH# oil 060 `60p CERTIFICATION G'�
00U
Property Address: 7 027 Ind lAl 57—"
-05£evi<� £ Address of ONncr:
Date of Inspection: _y 6. 97 (If different)
Name of Inspector: 7—RM� S SZA�P-S
Company Name, Address and Telephone Number:
A & B Canco 350 Main Street West Yarmouth, MA 02673 008) 775-2800
CERTIFICATION STATEMENT
I certify that I have personal3y inspected the sewage disposal system at this address and that-the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training
and experience in the proper function and
maintenance of on-site sews8e disposal systems. The di s stem:
Y
_ Passes
(-"Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspedion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional oMoe of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A.B,C,or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any bilure criteria not evaluated are indicated below.
I El SYSTEM CONDITIONALLY PASSES:
/One or more system Components need to be replaced or repaired. The system,upon oompletion of the replacement or repair; passes
inspection.
Indicate yes, no,or not determined(Y.N.or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
�. by the Board of Health.
(reviSed 11/03/95) I
Or4 Winn SIW90 1 500011,M0864chusettt 02108 0 FAX(617)5WI049 • T•lephont(617)292.5500
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspection:
Bl SYSTEM CONDITIONALLY PASSES(continued)
Sewage 011 breakout I i I I IMEMobserved in the distribution box is due to broken
distribution box. The system will
Health): Pa,"inspection if(with approval of the Board of
broken pipe(s)are replaced
obstruction is removed • .
♦YJ distribution box is 111Wreplaced
Al The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(&)are replaced
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
Public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF IiEALTII (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_, The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_• The system has a septic tank and&oil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
suppl,well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
g) OTHER
t
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: j
Owner.
Date of Inspection:
D) SYSTEM FAILS:
I have determined that the system violates one'or more of the following failure criteria as defined ' 310 CMR 15-303. The basis for
this determination is identified below. The Board of Health should be contacted to determine w t will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clo SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface wale due to an overloaded or clogged SAS or
cesspool. .
Static liquid level in the distribution box above outlet invert due to an verloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available vq ume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT/dto clogged or obstructed pipe(s).
Number of times pumped
— Any portion of the Soil Absorption System,cesspool or p vy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet fl a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zo e I of a public well.
Any portion of a cesspool or privy is within b feet of a private water supply well.
Any portion of a cesspool or privy is less 100 feet but greater than 60 feet imm a private water supply well with no
soceptoble water quality analysis. If t wgll l}as been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic cc undo,ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large stems in addition to the criteria above:
The system serves a facility with design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the en ' =eat because one or more of the following conditions exist:
the system is wi 400 feet of a surface drinking water supply
the system Is 'thin 200 feet of a tributary to a surface drinking water supply
the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area UWPA)or a mapped Zone II of a public
water ply well)
The owner or operator such
ope any system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 C 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/ /95) 3 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _
Owner.
Date of Inspection:
Check if the(following have been done:
V Pumping information was requested of the owner,occupant,and Board of Pa Health.
None of the system components have been pumped for at least two weeks and the system has been recei`�8' normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_jlAs built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
✓ The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
V All system components,IXcluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffies or
/tees,material of oonstruction,dimensions,depth of liquid,depth of sludge,depth of scum.
The sise and location of the Soil Absorption System on the site has been determined based on existing information or
ZThe
rcaimated by non-intrusive methods.
facility owner(and occupants, if different from owner)wero provided with information
t n on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL;,
Design flow-3TPO—sallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): N o f
Laundry oonnected to system(yes or no):�f £S
Seasonal use(yes or no):/V O
Water meter readings,if available: _
Last date o f occupancy: '
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ...... ons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present:(yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: g , s,I/ S o��+t£
7 4,-),,PA/ $ APT Q�C�4
System pumped as part of inspection: (yes or no)_
If yes,vohtme pumped: eallons
Reason for pumping:
TYPE 9F SYSTEM
Septic tanVdistribution baodsoil absorption system
Single cesspool
Overflow cesspool
Privy
— ibared system(Sr no) (if yes,attach previous inspection records, if any)
Ocher(esplaia>_ _ ���"k i=o,P 0-4-P E i 4,50 Pic%5 Pv P��7—vim B•[� f=
APPROXIMATE AGE of all components,date installed(if known)and source of information: I !e y• 89�� y£/9�� t�i`
Sewage odors detected when arriving at the site: (yes or no) /VO'
(�evt�ed 11/03/95) 6
� F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK
(locate on site plan)
Depth below grade: N�
Material of oonstrtution: F/ooncrete_metal_FRP_other(e:plain)
Dimensions: 1p
va G /°iP£ CgST
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 67
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bafne: /
Comments:
(recommendation for pumping,condition of inlet and outlet tees or bathes, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
GREASE TRAP._
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions:
Scum thickness:
Distance loom top of scum to top of outlet teo or baffle:
Distance&am bottom of scum to bottom of outlet We or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage.etc.)
E
(revised 11103/95) 6
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other explain)
Dimensions:
Capacity: sallons
Design flow: gallons/day
Alarm level:
Comments: 4
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: --
(note if keel and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
BOX iS -3' AL40Al G' 2)Z a0Xd-o ST£L (fiAc7£
PUMP CHAMBER:_
(locate on site plan) `
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(rtylud 11103/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address;
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan,If possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type leaching pits, number
1aching chambers,number:_
leaching galleries.number: 8.
leaching trenches,number,)ength:
leaching fields, number,dimensions:
overflow cesspool,number:
Comments: (note condition of soil,q u of hydraulic failure, level of pondin�condition of vegetation,etcJ
P�f P T S /£FC ('a -o
i T ,q�P /O'n G!J L £ / �'
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:(note Condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:(note Condition of soil.signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11105m) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all Wong within 100'
a
'DEPTH TO GROUNDWAvTEP
Depth to groundwater 1 feet
method of determination or approximation: �/ 2 S/ 141i L f O A✓
(revised 11/03/95) 9
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
IMF- fill
DATA
-' l.:_y. . ' - ,_i,/ ... '- •- I �\ "-�� ',�, , / ,r`..tip �•�.., f-..
. •�-_��.�+ .. _ � � � .'3Y`�_:j. 'e1l1._L .:nR' l'�',:•S�^'7f•.• 3.
/moo k
a
(Z)L
J � � v
o I
7
Commonwear h of Massachusetts RECEIVLED
Executive Office of Environmental Affairs
Department of JAN o 1997
Environmental Protection ` OWN OFBARNSTABLE
William F.Weld
Gowmor
T►udy Coxe
ECEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
MAP#Yl �,1/I/�11/iV0 I�No.4�C PART A `
PAR# D/,3-Oo� C oivvos ✓u/r�ERTIFICATION '-olllzl SA 171-71
Property Address: '7A7 MAiy 57r—SST
_ Address of Owner:
Date of Inspection: '? 96 (If different)
Name of Inspector: 7/—gm c $ Z SFA,PS
Company Name, Address and Telephone Number:
A & B Canco• 350 Main Street West Yarmouth, MA - 02673 (508) 775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at thus address and that the information reported below- is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems The system:
_ Passes
Conditionally Passes
Needs Funher Evaluation B% the local Appro�ing Authority
Fails
Inspector's Signature:, Date: 3—/b
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing th-5
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Deparimen! of Environmental Protection
the original should be sent to the syslem uv,net anti cup,t•> >r:„ to tirc i,�1c•:, 11 app'1cab;c a:ui 0_1 ap• ,o.in- au'how\-.
4
� rl
INSPECTION SUMMARY:
Check A B C or D
A], SYSTEM PASSES: \Y�Zdffi V
I have'not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need sto be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate.yes, no:or not determined (Y, N, or ND): Describe basis of determination in all instances. if"not determined", explain why not)
The.septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent..-The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as x.
approved by the Board of Health.
(revised 8/15/95) - 1
One Winter Street q a Boston,Massachusetts 02108 0 FAX(617)556 10491 9 "Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES (continued)
Sewa breakout observed in the distribution box is due to broken
distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
ll-Idistribution box is disoreplaced
N The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board'of Health):
broken pipe(s) are replaced
obstruction is removed
Cl FURTH EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condr 'ons exist which require further evaluation by the Board of Health in order determine if the system is failing to protect the
public h alth, safety and the environment.
1) SYSTEM W L PASS UNLESS BOARD OF HEALTH DETERMINES THAT E SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WIL PROTECT THE PUBLIC HEALTH AND SAFETY AND T E ENVIRONMENT:
_ Cesspo or privy is within 50 feet of a surface water
Cesspool r privy is within 50 feet of a bordering ve ated wetland or a salt marsh.
2) SYSTEM WILL FAIL LESS THE BOARD OF-HEALTH ( D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNC ONING IN A MANNER THAT ROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The sysien) has a s 11C tang and suli d'u 1Nriu11 anu 15 within 103 feel lc, a surfacE water supply or trbu;are to
surface water supply.
_ The system ha, a septi tank and soi absorption system and is within a Zone I of a public water supply well.
_ The system has a septic nk and it absorption system and is within 50 feet of a private water supply well.
_ The system has a septic t k an soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well at analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from tha acility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D) SYSTEM FAILS:
I have determined that the s tem violates on or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is id ntified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Nn _ Backup of s wage into facility or system omponent due to an overloaded or clogged SAS or cesspool.
_ Dischar or ponding of effluent to the su ace of the ground or surface waters due to an overloaded or clogged SAS of'
Cesspo I.
(revised 8/15/95) 2
F
r
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS(conti ed):
Static liq id level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool.
Liquid dep h in cesspool is less than 6" below invert or available volume is ess than 112 day flow. .
_ Required pu ping more than 4 times in the last year NOT due to clo or obstructed pipe(s). '
Number of ti s pumped
Any portion of th Soil Absorption System, cesspool or privy is be w the high groundwater elevation.
Any portion of a ce pool or privy is within 100 feet of a surf a water supply or tributary to a surface water supply.
Any portion of a cessp of or privy is within a Zone I of a blic well.
Any portion of a cesspool r privy is within 50 feet of private water supply well.
Any portion of a cesspool or rivy is less than 100 et but greater than 50 feet from a private water supply well with no
acceptable water quality analy is. If the well has en analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organ compounds, monia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in ition to the criteria above:
The design flow of system is 10,000 gpd or eater arge System) and the system is a significant threat to public health and safety
and the environment because one or more f the foil wing conditions exist:
the system is within 400 feet a surface drin ing water supply
the system is within 200 fe of a tributary to a s rface drinking water supply
the system is located in nitrogen sensitive area (I terim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply w I)
The owner or operator of any such sy em shall bring the system and fa lity into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and .00. Please consult the local region I office of the Department for further information..
trevised'8/15/95) 3
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the followinghave been done:
Pumping information was requested of the owner, occupant, and Board of Health.
ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
Vduring that period. Large volumes of water have not been introduced into the system recently or as part of.this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
I/The system does not receive non-sanitary or industrial waste flow
Ae site was inspected for signs of breakout.
Y All system components, dxcludin the Soil Absorption System, have been located on the site.
` / Y P g P
v The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
• tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
N/ The size and location of the Soil Absorption System on the site has been determined based on existing information or
pproximated by non-intrusive methods.
Y The iacihi-) u%%iw: lead uccup.r.;o, if d,;icrr,: irjr,-. :;r%nc:, %erc pro%idcd �%i;h information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
i
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design- flow: Y M gallons
114'Number of bedrooms: B r
Number of current residents: O
Garbage grinder (yes or no):__/VO
Laundry connected to system(yes or no):--�F5
Seasonal use (yes or no): ND
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: rtallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
F/��PL r' Pvm Pi.v G
System pumped as part of inspection: (yes or no) O
If yes, volume pumnee gallons
Reason for pumping.
TYPE QF SYSTEM `
�/ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if.any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information: M00
Sewage odors detected when arriving at the site: (yes or no) o
(revised 8/15/95) S
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
a
Depth below grade: �'y
Material of construction /C.ncrete _metal _FRP other(explain)
Dimensions: 00
Sludge depth: �y
Distance from top of sludge to bottom of outlet tee or baffle: y
Scum thickness: I 1,
Distance from top of scum to top of outlet tee or baffle: ��
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to out et invert, tructural
integrity, evidence of leakage, etc.) ;31A 7- W01e iL� f�/f< a /Ai.4£T ��/�Fs
iP I ££ iP£ /Vo £r O VT £7- 44 F L£,
eoyrAIS S stL 01 OiVF /47- 11'AD1 ov7,4£T oul.E'
B sLow Aa£
/V oT h/A of/41.,4 J'T' '7'-f F, i0N ST.44A..117
GREASE TRAP:_ ,
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to ton of outlet tee or baffle: u
Distance fro•r hotio, hntlnm Of oo!lot tPP or baffle'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of IeakaeP, etc )
•
(revised 8/15/95) 6
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: -
Comments:
(note If level and dsn e.idr^ce or<�1„f• cz•^.n.e�. evidence of leakage in o or out of box, etc.I
lB oX � S �3".X, 3C�'-• a0 " Q&Low 611?'9zz , slbz of o SS
O EAI ox, Ayff17 's /o PLACED
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
r
(revised 8/15/95) ! " 7 "
M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):!
(locate on site plan, if possible; excavation not required, but may be approximated_by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: T
leaching chambers, number:_
leaching galleries, number:
leaching trenches; number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: to condition of soil si ns of hydraulic failure I vel of p ding, condition of vegetation,etc.)
iT IV oT Alf"21'£A- IFS
e f - a Pi Ts i i✓ Pf+iA/t��v�- �vT .
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: _
Dimensions of cesspool
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, sign_ of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
I
r
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) "
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or'benchmarks
locate all wells within 100'
O
O
ODEPTH TO GROUNDWATER .
Depth to groundwater: feet
method of determination or approximation:
(revised 8/15/95) 9
SEPTIC PUMPING AND INSTALLATION 350 Main St. • W. Yarmouth, MA 02673ws;:775-[600
Heating&Plumbing,Fire Sprinklers
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM '
Address of property 03,E ,' MAP#_S/
Owner's name ow-4
Date of Inspection RECEIVED
- Qd o
PART A J A N to 1997
CHECKLIST HEALn:D�PT.
i TOWN OF BARNSTABLE
Check if the following/have been done:
Pumping information was requested of the owner, occupant, and Board of
alth.
None of the system components have been pumped for at least two weeks
and the system has,. been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
�ys-tem recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A f
The facility or dwelling was inspected for signs of sewage back-up.
v The site was inspected for signs of breakout.
All system components, excluding the SAS, have ,been,,,located`on the
site.
The septic tank manholes were uncovered, opened, and -the interior of
the septic tank was inspected for condition of. baffles or tees,
material of construction, dimensions , depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive. methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS. ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
<' SYSTEM INFORMATION
FLOW CONDITIONS
Ijk residential
number of bedrooms
(irddtwe d number of current residents
garbage grinder, yes or no
laundry connected to system,- yes or no
seasonal use, yes or no
If nonresidential , calculated a f low:V �y'Q�- j6 ODD
Water meter readings, if available: 00271
Last date of occupancy
GENERAL INFORMATION
Ptamping records and source of i f r ation:
System pumped as part of inspection, yes or no
if yes, volume pumped
,gy Reason for pumping:
Type,,pf system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
—� Shared system (yes or no) ( if yes , attach previous inspection'
1'—r". records, if any) ,
Other (explain) '
Approximate age of all co ponents. Date ins ta led, if known' Source of
information: o vac z
Sewage odors detected when arriving at the site, yes oroo
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
J SEPTIC TANK: SYSTEM INFORMATION continued
7�S
(locate on site plan)
depth below grade: ��
4material of construction: yconcrete metal FRP other explain)
d'iie"nsions:
( sludge depth
distance from top of sludge to bottom of outlet tee or baffle
O scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. ) '
`/W A<l%£ -Sv 7w�-
DISTRIBUTION BOX:
locate on site plan)
0 depth of liquid level- above outlet invert
Comments: "
(note if level and distribution is equal , evidence of solids carryover, ?
evidence of leakage into or out of box, recommendation for repairs, etc. )
X IV6, ya ng cw� , a�s�rL a `� ,f ox
PUMP CHAMBER: IV ow
(locate on site plan)
pumps in working order, yes or' no
Comments:
441 a condition of pump chamber, of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
a
F
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:< . PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS).:
#` (locate on site plan, if possible; excavation not required, but may be
f}
approximated by non-intrusive methods)
If not determined to be present , explain:
leaching
g pits and nu 6d., /A�
eaching chambers and number
leaching galleries and number
leaching trenches , number, length
Teaching fields, number , dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic. failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
00/T5 LvvA� /rvf
$:. N �!
CESSPOOLS (locate on site plan) :
Y.
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
dimensions of cesspool
materials of construction
indication of groundwater
..;inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations, for maintenance or repairs, etc. )
PRIVY: dU CAI E
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments: i -
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
Lim,
h
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
j" locate all wells within 100 '
f'
o
DEPTH TO GROUNDWATER `
depth to groundwater
method -of determination of approximation:
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not
Al Backup of sewage into facility?
Al Discharge or ponding of effluent to the surface of the ground or
surface waters?
Al Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/ : da
flow?
IV- '"Required pumping 4 times or more in the last year?
number of times pumped
Al Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
, A-1 within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface .
water supply?
Al within a Zone I of a public well?
/N" within 50 feet of a private water supply well?
-less than 100 feet but greater the 50 feet from a private water suppl
well with no acceptable water quality analysis? If the well has been
analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds , ammonia nitrogen and
nitrate nitrogen.
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name A & B Canco
i
Company Address 350 Main Street , West Yarmouth MA 02673
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems .
Check,�one:
' I' have not found any information which indicates that the system fail
to adequately protect public health or the environment as defined in
310 CMR 15 . 303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . Any failure criteria
not evaluated are as stated in the FAILURE CRITERIA section of this
form.
NOTE: A & B Canco has had no control over the use and/or routine
maintenance of the septic system. Circumstances such as a recent pumping
will significantly alter evaluation results. No guarantee or warranty is
hereby given, express or implied, as to the evaluation.
THE ISSUANCE OF THIS INSPECTION FORM SHALL NOT BE CONSTRUED AS A GUARANTEE
THAT THE SYSTEM WILL FUNCTION SATISFACTORILY
I-f�you;:have any questions , please call me at 508-775-2800 between 8: 30 'am
and 4: 30 pm, Monday through . Friday.
Inspector 's Signature
Date
Original to system owner
Copies to:
f
Buyer ( if applicable)
Approving authority
f
�I r✓/ �� �/i�� tip •.l ,,ki-�}'� � ��� .J t�i�l yws.�t�t`.:
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' �� �_ - !«• 4 - 'i _- _ i ;r t•.[i j•L P•.ei R� . .G.��r•r °:b(�•d•�%4"• -
� � � � .-�\ �+f..�` .#'' tc.+•. .c .eft' .C''•.
' '. - :..+is•�ca.+4 �J� ........ _,�,,. —��,,;._.•'' `.t�!�`•' � ,S3 i t .�. � .�`�•F�•_�,
e+•�.-�'.' �.R ram.•ems- ,a •� �y} _ r � .+L -1 l .r
may} r.'_ ., •. y.
.,.�.,-r+. h?�w'.�;ssy- zawwar,. .� •'•�t:.'' l�. :\ L � yl ! v� �,:.r i i � ��:Tt'-+t'i�.. .. �}sl � ��
tr
SEPTIC PUMPING AND INSTALLATION 350 Main St. • W. Yarmouth, MA 02673 • 775-2800
Healing&Plumbing,Fire Sprinklers
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,/17/1/N'
Address of property 7 ? 7 N����' �' kti��_�_ MAP#
Owner's name ` 7_;P F v -17 Rr 0_15
Date of Inspection ppR 0
_,9-1 RECEIVED
PART A JAN ® 1997
CHECKLIST
HEALn:D�PT.
Check if the following have been done, TOWN OFWNSTABLE
Pumping information was requested of the owner, a occu
Health. P nt, and Board of
None of the system components have been for
pumped at least two weeks 4
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A
The facility or dwelling was inspected for signs of sewage back-up.
P
The site was inspected for signs of breakout.
y ,,All system components , excluding the SAS, have been...located`Ar tba
site.
The septic tank manholes were uncovered, opened, and *the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions , depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
f on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
f
8 -
f(t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential v✓iT-6--
a number of bedrooms
o number of current residents
garbage grinder, yes or
laundry connected to s stem, es or no
seasonal use, yes or no
> pC CAL URC.t ��
If nonresidential , calculated flow, �- `/� U
Water meter readings, if available:
VN /fivv�v Last date of occupancy
GENERAL INFORMATION
Pumping records and source of
information,-,
System pumped as part of inspection, yes or no!
if yes, volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) ( if yes , attach previous inspection`
records, if any)
Other (explain)
Approximate .age of all components . Date installed, if known. Source of
-information,
I-I ,ELT/� T
Sewage: odors detected when arriving at the site, yes or ono -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK
: V
E (locate on site plan)
depth below grade:
material of construction: /Concrete metal FRP other(ex lain
P )
dimensions: 2000 4 %
•5 sludge depth
distance from top of sludge to bottom of outlet tee or. baffle
0 scum thickness
_L distance from top of scum to top of outlet tee or baffle
_1( distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
l,v k 7Z;1tik N T
DISTRIBUTION BOX: / £5
(locate on site plan)
G depth of liquid level above outlet invert
Comments: _
(note ,if level and distribution is, equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER: /VOk' E
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber , of pumps and appurtenances,
recommendations for maintenance or repairs , etc. )
r
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART' B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS),: VIs
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
Ifnot determined to be present , explain:
' 017 V0 c v t iE' Gy suR��CL vn�Jf,P
9
Type
leaching pits and number
. leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields , number, dimensions
overflow cesspool , number
Comments: --
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of Vegetation, recompendations for maintenance or repairs, etc. )
PiT :7£"tom -fL T,e 'D Bah ,v�r- tLr.L
/ Per
BN,' ri-�/// moo- /�9a1% s�= /=�cw - fi7- 2. G 'i�,i -Y ��G✓9Tie
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert' '
depth of solids layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped. as
part of inspection)
Comments:
(note condition of soil , signs of . hydraulic failure, level of ponding,
condition of vegetation, recommendations ,for maintenance or repairs, . etc. )
PRIVY: V
(locate on site plan)
materials of construction
dimensions
depth of solids '—
Comments: —
(note conditionof soil , signs of hydraulic failure, level of ponding,
condition of- vegetation, recommendations for maintenance or repairs , etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
E N FORM
PARV B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM,
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Q/r
8� qD
I
1
DEPTH GROUNDWATER
N0 wg f,c gr
a ,
/� - depth to groundwater
method of determination of approximatior_L—
£ Ow Co N$ �'( C'�'�li.✓ �fiCh// 0�-y/1 .,
SURFACE SEWAGE DISPOSSAALLTSYSTEM INSPECTION FORM
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" ,explain why not
i
Backup of sewage into- facility?
Al Discharge or ponding of effluent to the surface of the. ground or
surface waters?
Al Static liquid level in the distribution box above outlet invert?
/✓ Liquid depth in cesspool <6" below invert or available volume< 1/2 da
flow?
�✓ Required pumping 4 times or more in the last year? ,
number of times pumped
I✓ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
.below the high groundwater elevation?
. A/ 4
within 50 feet of a surface water?
Al within 100 feet of a surface water supply or tributary to a surface
water supply?
-Al within a Zone I of a public well?
Al within 50 feet of a private water supply well?
less than 100 feet but greater the 50 feet from a private water suppl
well with no acceptable water quality analysis? If the well has been
analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds , ammonia nitrogen and
nitrate nitrogen.
f
,v4-.s11ouA,D/ , _q
1�90X =rD
/F.��9
• 4
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector , qM Es
Company Name A & B Canco
Company Address 350 Main Street , West Yarmouth MA 02673
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
i
Chpone:
I have not found any information which indicates that the system fail
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
T' have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303. Any failure criteria
not evaluated are as stated in the FAILURE CRITERIA section of this
form.
NOTE, A & B Canco has had no control over the use and/or routine
maintenance of the septic system. Circumstances such as a recent pumping
will significantly alter evaluation results. No guarantee or warranty is
hereby given, express or implied, as to the evaluation.
THE -ISSUANCE OF THIS INSPECTION FORM SHALL NOT BE CONSTRUED AS A GUARANTEE
THAT THE SYSTEM WILL FUNCTION SATISFACTORILY
If you have' any questions , please call me at 508-775-2800 between 8: 30 am
and 4: 30 pm, Monday through Friday.
Inspector 's Signature,/�� `
Original to system owner
Copies to:
Buyer (if applicable)
'Approving authority '
i
TOWN OF BARNSTABLE
LOCAiCN SEWAGE #
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PDATE:_`Z'Iti' �,�'1%�. COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by bA�R�
r �
tC-)
�z-alp ®2 rb
� 3`
COMMONWEALTH OF MASSACHUSETTS (DECFICE OF ENVIRONMENTAL AFF
o;.
DEPARTMENT OF ENVIRONMENTAL PROTEC N RE�an
0 08 6 7 9 . N
ONE WINTER STREET, BOSTON MA 21 ( 1 )2 2 5500
DEC C
WILLIAM F.WELD 'K UDY CORE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt. Governor `Commissioner
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: (1J%#*,*-Wc, tcsTt4ak k Lk—. Address of Owner:
Date of Inspection: l?�1b (If different) lZ3 L.Nca�„J S�
Name of Inspector:I.�,�
Company Name, Address and Telephone Number: M►4•
C`2lec1� SG@^y�l�—1 L{ZD
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: V-__VS 5
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B,C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/95) 1
`�Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:14
B] SYSTEM CONDITIONALLY ASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
roken pipe(s) are replaced
_-___- .------- struction is removed --
ribution box is levelled or replaced
The system required mping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with app val of the Board of Health):
brok n pipe(s) are replaced
obstr ion is removed
C] FURTHER EVALUATION IS REQUIRED BY E BOARD OF HEALTH:
Conditions exist which require further eva ation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
i) SYSTEM WILL PASS UNLESS BOARD OF HEA H DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH ND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a s ace water
Cesspool or privy is within 50 feet of a bo ering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALT (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THA ROTECTs THE PUBLIC HEALTH.AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption s stem and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption sys m and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption syst and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption syste and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for col iform b cteria and volatile organic compounds indicates that the well is .
free from pollution from that facility and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm-
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (0% Kr-Vt
Owner: P.PIP tJ:!�'
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):---
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: 2AGX(,9T5
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
evo
CESSPOOLS: _V
(locate on site plan)
Number and configuration: -
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: 4
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: �a
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYST M INSPECTION FORM
PART C
SYSTEM INFORMATION ontinued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, et .)
DISTRIBUTION BOX: /idss
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of sryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, conditi numps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert Address:
Owner,VIPP J
Date of Inspection: kZ`t3�9L.
SEPTIC TANK:-S�t S
(locate on site plan)
i
Depth below grade: kT N'LW1>'—
Material of construction: concrete _metal _FRP other(explain)
Dimensions:
Sludge depth: O"
Distance from top of sludge to bottom of outlet tee or baffle: 3y '
Scum thickness: 3
Distance from top of scum to top of outlet tee or baffle: to
�`
Distance from bottom of scum to bottom of outlet tee or baffle: l 3��
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
i tegrity, evidence of leakage, etc.) 1U t e$-
v
GREASE TRAP:_jJ0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 0.1%+RNn)o VW.aolk v-6Z
Owner:'4"pp-,
Date of Inspection:
'FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0G0 gallons
Number of bedrooms: W
Number of current residents: C>
- Garbage grinder-(yes or no): - - -. _ - - -- - -
Laundry connected to system (yes or no):�v�S
Seasonal use (yes or no):NO .
Water meter readings, if available: uAft.
Last date of occupancy: 1�5�
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) .�v
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
_K Other(explain)_5S*Zl c
APPROXIMATE AGE of all components, date installed (if known) and source of information: \O!@,
Sewage odors detected when arriving at the site: (yes or no)�v
(revised 11/03/95) 5
r
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
I have determined that the stem violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is iden 'tied below. The Board of Health should be contacted to determine what will be necessary to correct
�. _ .. the failure: - -- - -- -- -- - -
Backup of sewage into cility or system component due to an overloaded or clogged SAS or cesspool.
Discharge.or ponding of luent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distr ution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less han 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 ti es in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption S tem, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is wi in 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is with a Zone I of a public well.
Any portion of a cesspool or privy is within 0 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable.water quality analysis. If the well h been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, a monia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the riteria above:
The system serves a facility with a design flow of 10,000 gpd or reater (Large System) and the system is a significant threat to
public health and safety and the environment because one or mo of the following conditions exist:
the system is within 400 feet of a surface drinking water s ply
the system is within 200 feet of a tributary to a surface drink ng water supply
the system is located in a nitrogen sensitive area (Interim Well ead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full ompliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of th Department for further information.
(revised 11/03/95) 3
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: V_%poo"o
Owner: P-PP"A."
Date of Inspection:
Check if the following have been done:
k Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are riot available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
, The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
I�
• E 1.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: W►r.v-TJca C1N T �2
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
ilia v..s.r 9 Z
yCD
�a
I '
DEPTH TO GROUNDWATER
Depth to groundwater: 11'� feet (�
method of determination or approximation: �L S_ `a C I e Z. �y►e y4
v
(revised 11/03/95) 9
FEx
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA TH
.�jY..L.......OF..:... . ... ....-----
AV- phratinn for UWposal Marks Tonstrurtiuu Vamit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage. Disposal
System at:
x1= ` .
Location-A ess or Lot No.
Owne Address
Installer Address
1� Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------------------••--_--__•___-.-----------F_xpansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
d Other fixtures ...............................
W Design Flow...........................................gallons per person per day. Total daily flow--------------------------------------------gallons.
W Septic T:tnk, Liquid capacity----__--___gallons Length................ Width----.---_ .... Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.--_--.___-----_____sq. ft.
Seepage Pit No...................•. Diameter..................... Depth below inlet........._.......... Total leaching area------:...........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------....
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--___--------_._--_-.__
Gxq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.__.--__--.____----.---
W •---••......-•----------------•-••................................................=......................................................................... . .
O Description of Soil_______________
x ------------------------------------- 7.... 3-Y----------------------------------------------------------------
V Nature of Repairs or Alterations—Answer d6hen applicable._____________________--------------------------------_-------------------------------_---------
----•-•----------------•---•-••----•--------•------------------•--•--•-••--•---------------------•------•----•----------- --------------------------------------------- ----------•-------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the b and f he t .
7-
Sign d -- .
D to
Application Approved By--------- ---- ----_ •-----l�ll�✓� --------------------
Date
Application Disapproved for the following reasons------------------------•- -------------------------------------------------------------------------------••--•-
....•••-•-.... .
Date
PermitNo......................................................... Issued........................................................
Date ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH '
... j...............O F. ...........................
f krfif Irate of Tompliattr
THIS IS TO CERTIFY, That the Individual Sewage Disposal.,System ,constructed ( ) or Repaired ( )
by----------------------- .................... ------ - _... =
Installer q r 3
has been installed in accordance with the provisions of Article XZ.•of The State Sanitary Code desc 'be in the
application for Disposal Works"Construction Permit No. __ __ ___/ rf�_ ------- dated. .._. ._-.14- _7 ._:...._..
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................................----------................. Inspector.,----------------------------
•••Y r•••.r♦Y r•••r••I I Y r• �............ ......... •'. +.e��t 1 ?•;�•n �.•.I.of)•r•1:Y!'f•�'i^"n•'•.•1 t••�v r♦♦Y Y•r••�.Y. �' '�Y�r Y••.•n/ •4 n r .•-
THE COMMONWEALTH OF MASSACHUSETTS
4
BOARD HE TH
1�"� f2,iLti............ o F.... t ------------------
No. --------------•-- FEE-
'Permission is hereby granted.............................. ......................................................-- ------------------------------------------•--.......
to Construct (J J o
epair ( ) an ivid a Sewage Disposal Systej
at No._. 7 ... = . ......
�
------- -- --- -
Street I ;
3"
as shown on the-application for Disposal Works Construction Per No._._/: ____ Dated__3 �
___. - r_...
Board of Health
DATE------------------........................................................... v
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STING SEPTIC TANK �''' •—.�
EXISTING WATER / PROPOSED 12 - 500 GAL. H-20
-- A SERVICE LINEO 3
��/ 19X5' NF ONE IN A TRENCH
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61.71'
/ 22" OAK
EXISTING SIGN 3 • • r • b
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EXISTING FOUNDATION / f _ t. ti n PARKING AREA
SLAB AREA
TO BE
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WIANNO KNOLL CONf/OMINIUMS
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—24 —
26— Z /17" OAK
� LIGHT POLE
____ --- — 28—
BRICK STEPS --- --.,
% \� STONE RETAINING WALLS /
EXISTING 2,500 GAL. SEPTIC TANK '
/ TO BE UTILIZED IN THIS DESIGN / � MAP 141
a " PROPOSED 2,000 GAL. LOT 12
H 20 SEPTIC TANK
MAP 141
LOT 13
83,579.±S.F.
/ h /
/ n /
BUILDING
WIANNO KNOLL CON OMINIUMS
/ n / 441
/ o .
/ Y `
/ °
/ do r